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Survey '' 3 Cc
of
Public Health Nursing
in
Connecticut
BY
HELEN F. BOYD
CONNECTICUT
STATE DEPARTMENT OF HEALTH
1918
PUBLIC HEALTH NURSE SURVEY
LETTER OF TRANSMITTAL
wv
log
87??
I ? I ST NATIONAL LIBRARY OF MEDICINE
WASHINGTON, D. C. New York ' N> Y "
L ' ' DE. JOHN T. BLACK,
Commissioner of Health of the State of Connecticut:
Dear Sir: —
This survey of the public health nursing done in Connecticut was un-
dertaken at your request and at the request of the Public Health Coun-
cil of the State of Connecticut. I was enabled to undertake the work by
the courtesy of the Nursing Committee of the Mayor's Committee of
Women on National Defense, in New York, who released me from my
work with them, and of the Nursing Committee of the General Medical
Board of the Council of National Defense, who undertook the burden of
my expenses for the two months of December and January.
The purpose of the survey was to find out how much public health
nursing is being done in Connecticut, and to find out in so far as pos-
sible the field being covered in infant welfare work, school nursing, in-
dustrial nursing, and general visiting nursing. In view of the fact that
the conditions induced by the war make it especially urgent that every
measure be taken for the fight against tuberculosis, for the protection of
infancy, and for safe-guarding the health of the people, a plan is
drawn up for a state campaign to increase such work, w T here the survey
shows the greatest need. Julia Lathrop, Chief of the Federal Children's
Bureau, says in her fifth annual report:
' ' The pressing essentials of a reasonable child welfare program for
the United States in war time may be condensed under four heads:
1. Public protection of maternity and infancy.
Essentials: (a) Public Health nurses and suitable medical attention;
(b) The care of babies by their own mothers under decent home con-
ditions. ' '
The scope of the investigation was necessarily limited as the survey
had to be finished in two months. The number of public health nurses and
the territory they covered was studied in proportion to the number of
persons reached by these nurses. Little w T as done in considering meth-
ods of organization or of technique of the nursing personnel, as neither
of these points could adequately be studied in the allotted time. More-
over, since it is now recognized by almost all that only a graduate nurse
with special training in public health work should be engaged in the
important task of public health nursing, it seemed best not to try to
touch the finer points of the technique of field w r ork. Out of the 272
public health nurses in the state, fifteen are not graduate nurses, and
eleven of these are doing industrial work. This would seem to point to
the natural death of such unscientific work, at least, in the field of gen-
eral visiting nursing, infant welfare, tuberculosis and school nursing.
Short trips were taken to places which were considered examples of
varying types of community. One was through the tobacco country
PUBLIC HEALTH NURSE SURVEY
from Hartford through Windsor Locks and Windsor to Suffield. An-
other was to the munition cities of Waterbury, Bridgeport and New
Haven. The large textile mill town of Willimantic and the series of
small mill towns from Putnam through Killingly, Plainfield and Norwich
to New London were visited.
The group of congested mill towns: Ansonia, Derby, Shelton and Sey-
mour were visited as having the problems both of congestion and for-
eign labor with high infant mortality rate. In all, twenty-three differ-
ent towns were visited.
There is an amount of public health nursing work already started that
shows a good growth during the past years, yet there are large stretches
where no work of any kind is done. Even in these places it is not an
uncommon thing to find that some group of interested citizens is con-
sidering the possibility of having a nurse. There has been a good foun-
dation laid for further work.
The survey has been a pleasant task. It would have been impossible
to have had so correct a list of nurses without the assistance of Mr.
Godard and Miss Albaugh who were in charge of the State Military
Census. Miss Corcoran of the Department of Factory Inspection, pro-
vided me with the latest list of industrial nurses, and invaluable assist-
ance in planning the ground that could be covered by more public health
nurses. The Board of Education give me their 1917 list of school
nurses. The public health nurses all over the state were most kind in
furnishing the necessary information. Most of the work was done from
Hartford, where I was allowed to make my headquarters, in the offices of
the Department of Health, where the office force was most helpful.
Hearty thanks are due all for their cordial co-operation. More than all,
Dr. C. E. A. Winslow has given his time and interest to make this re-
port of value for Connecticut.
Through the interest of the Committee on Medical Inspection of the
Women's Committee of the State Council of National Defense, of which
Dr. Kate C. Mead is chairman, and of the Committee on the Health and
Welfare of Children, of which Mrs. W. E. D. Scott is chairman, both of
which committees had taken as part of their war program the promot-
ing of public health nursing in the state, it was possible to' offer to the
lecturers of the Granges and others interested, a lecturer who should
address the individual Grange on the subject of public health nursing,
using slides which Dr. Brown, of Bridgeport, has kindly offered to lend.
It is hoped that these committees will stimulate local interest so that
specific localities where the survey shows the need, will as a war-time
measure organize for the employment of a public health nurse who will
be an important factor in conserving the health of the people and the
lives of the babies.
Respectfully yours,
HELEN F. BOYD.
February 9, 1918.
PUBLIC HEALTH NURSE SURVEY
PUBLIC HEALTH NURSE SURVEY
I
A SURVEY OF PUBLIC HEALTH NURSING
IN CONNECTICUT AND A PLAN FOR
ITS FUTURE DEVELOPMENT.
Purpose.
In December, 1917, the survey of the public health nursing in Con-
necticut was begun at the request of Dr. John T. Black, State Commis-
sioner of Health, and of the Public Health Council. The purpose was in
direct response to the widespread feeling in the country, induced by the
records of the foreign countries at war, that those of us who remain at-
home have two duties to perform. First, we must join heartily in every
effort directed toward increasing the success of the armies abroad wheth-
er in releasing our men for service, or in conserving food and fuel that
they may be provided. Second, that we at home must work to keep our
own country in good condition — we must work harder than ever before
to give each person, and especially each baby, in the country a chance
to be healthy and happy. Only by doing this can we expect to be ready
to cope with the problems that will come upon us in the reconstruction
period that must inevitably follow the war.
Julia Lathrop, Chief of the Federal Children's Bureau, says in her
fifth annual report, that one of the pressing essentials of a reasonable
child-welfare program for the United States in war time is the public
protection of maternity and infancy. (Last year 15,000 mothers and
300,000 children under five years of age died. Most of these deaths were
preventable.) And the two essentials for carrying out this program are:
(a) Public health nurses and suitable medical attention; (b) the care of
babies by their own mothers under decent home conditions.
Field of the Survey.
Connecticut is a small state with only * 1,355,492 inhabitants. It is,
however, one of the most important states industrially. A competent
authority says that Connecticut is making in the south central cities of
the state, 75 per cent of the munitions that are being made in the coun-
try. The large textile mills, making threads and cloths of different sorts,
are situated all along the swiftly running streams in the eastern part
of the state. The tracts in the north central part of the state are cul-
tivated to tobacco.
•Population estimated by applying ratio of school census of 1916 to national
census.
2
PUBLIC HEALTH NURSE SURVEY
It is these industries that have brought into the state the foreign la-
borers who make up such a large part of the population.
In the industrial cities like Waterbury, Bridgeport, New Haven and
Hartford, almost every nationality is represented in the labor supply.
The Poles and Italians predominate, with smaller districts of Lithuan-
ians, Albanians, Germans, Eussians, etc.
In the mill towns in the eastern part of the state there are large num-
bers of French, who have settled this part of the country during the past
fifty years. In some towns one hears only French spoken on the streets
and in the shops.
The tobacco country gets its labor in the summer from a floating pop-
ulation of Poles, Italians, and, during the past few years, of southern
negroes. The winter work in the warehouse is done by the resident
Poles and Italians. Women do a great deal of this work. The health
officer and the visiting nurse in one small town whose entire industry is
tobacco, reported that the Polish mothers work in the fields. In conse-
quence they are unable to nurse their babies, or properly to care for
their children. Moreover, they work all through their pregnancy and go
back to work too soon after delivery. The law that forbids a mother to
work in a factory four weeks before or four weeks after confinement, is
not applicable to the agricultural worker.
A brief study was made of selected places to try and gauge the pub-
lic health nursing needs of the towns and how the needs are being met.
For this purpose, several rural townships in the tobacco country were
visited; five of the towns where the munition manufactures have caused
an unusual influx of foreign labor; a series of mill towns and three cities
in the eastern section where the great textile industries are. In all
twenty-three different townships representing the different sorts of
communities were visited. The infant welfare work, general visiting
nursing where bed-side care is given to the sick in their homes, tubercu-
losis, school nursing and industrial nursing were studied. This study
does not include private nursing nor institutional work. Organization
and methods were only slightly considered, as it was possible in the al-
lotted time to find only the extent of public health nursing in the state.
PUBLIC HEALTH NURSE SURVEY
3
General Visiting Nursing.
TABLE 1.
'Ratio of general visiting nurse to population of towns arranged ac-
cording to their size.
Towns with
Towns with
less than
3,000 to
Towns with
5,000 popu-
10,000 pop-
over 10,000
Towns
Population
No. of
lation per
ulation per
population
with
of towns
towns
nurse
nurse
per nurse
no nurse
Under 5,000 .
. 120
11
0
0
109
5,000-10,000 . .
. 21
1
6
0
14
10,000-15,000 .
. 10
0
1
5
4
15,000-25,000 .
8
1
2
5
0
25,000-75,000 .
5
0
4
1
0
75,000-160,000
4
1
2
1
0
168
14
15
12 .
127
♦General visiting nurse includes the tuberculosis nurse, the infant welfare
nurse, and the hospital social service nurse. Lists procured from State Military
Census, National Organization for Public Health Nursing and Connecticut Or-
ganization for Public Health Nursing.
Table 1 shows that only fourteen of the 168 townships of Connecticut
have anywhere nearly adequate general visiting nursing service. Only
one large city, New Haven, is in the first class with one nurse per 4,600
population. Fifteen towns are taking fairly good care of their people
in this direction, and 12 have begun to see the need of this work. 127
representing a population of 317,526, have no general visiting nurses,
although a number are beginning to realize what the public health nurse
can do for a community.
The general sickness needs of communities are being recognized more
fully now than ever before. Sickness surveys have shown that about
two per cent of the population are ill* during the year, each person with
length of illness averaging six days in California to 7.9 days in Boston.
Of this number hardly 10 per cent are cared for in hospitals. 90 per cent
are sick in their homes. It is this 90 per cent that the general visiting
nurse cares for.
But more important than the care of the sick, necessary as it is, is
the preventive work that the public health nurse can do.
♦Sickness in Dutchess County, New York — State Charities Aid Association.
2. A Sickness Survey of Boston, Mass., by Lee K. Frankel, Ph. D. and Louis
I. Dublin, Ph. D.
3. A Sickness Survey of Pittsburg, Pa., by L. K. Frankel and L. I. Dublin.
4. Maternity and Infant Care in a Rural County in Kansas, by Elizabeth
Moore of the Children's Bureau.
5. Report of Social Insurance Commission of the State of California.
PUBLIC HEALTH NURSE SURVEY
Pre-natal Nursing.
First and foremost of the preventive work is the work for the babies,
and first and foremost of the work for infants in its results is pre-natal
nursing. The accompany diagram shows the remarkable results in
Boston where pre-natal care was given at the Boston Dispensary. It
shows how by giving pre-natal care and advice to mothers, about half
as many babies die as when the mothers have no such help.* In all Con-
necticut there are only two nurses who are giving pre-natal advice witht
adequate facilities for physical examination of patients, urine examina-
tions and blood pressuie examinations with follow-up work. This is be-
ing done from the New Haven Dispensary. In the Hartford Dispensary
an obstetrical clinic has been started, but the doctor in charge withdrew
to war duty and this vital work has been dropped. It is encouraging,
however, to find on every side an awakened interest in the work. Every
nurse is alive to the need of this service and each and every one is giv-
ing a good deal of pre-natal advice in an unsystematic way.
The possibility of improving the mortality among mothers has been
demonstrated by the experience of the Metropolitan Life Insurance Com-
pany. At a time when childbirth mortality in the country as a whole
was stationary, the death rate from this cause among women between
fifteen and forty-four years of age was reduced in the period 1911-1916
by 10.7 per cent among its white policy holders, and by 20.4 per cent
among its colored policy holders. "The more favorable condition among
the insured females," says the company, "is in large measure the result
of the extensive care given by the visiting nursing service of the com-
pany to policy holders during pregnancy and after childbirth."
The pre-natal nurse visits the patient, makes sure that she follows the
simple rules of personal hygiene and diet, supplementing and enforcing
the doctor's care. Practically, we too often find that won en will call in
the doctor only at the last moment for the delivery. The nurse can of-
ten use her influence to get such women to realize the need of care dur-
ing pregnancy. Often she can use her skill in more serious conditions,
as in the following case in New York:
Mary A., twenty-seven years old, had lost one baby by miscarriage.
The visiting nurse found that Mary was five months pregnant, but could
not persuade her to go to the dispensary nor to a doctor. Fearing that
the first miscarriage had been due to kidney trouble, the nurse had
Mary 'g urine examined. The urine showed a large amount of albumen.
♦Michael M. Davis — The Beneficial Results of Pre-natal Work.
tPr. J. Whitridge Williams gives the following:
Adequate care means :
1. A general physical examination, including an examination of heart,
lungs and abdomen.
2. Measurement of the pelvis in a first pregnancy to determine whether
there is any deformity which is likely to interfere with birth.
3. Continued supervision by the physician at least during the last five
months of pregnancy.
4. Monthly examination of the urine, at least during the last five month?.
6
PUHLIC HEALTH NURSE SURVEY
Mary was at once sent to the hospital where she was Immediately put
on a careful diet. She yielded quickly to treatment and in due course
of time a health}' boy was born. Undoubtedly, by the nurse 's prompt
action, Mary's health and the baby's life were saved.
The need of pre-natal care cannot be too much emphasized. Not only
New Haven but the whole state needs it. It is the right of every moth-
er to have the best possible care during the period of pregnancy.
Nursing Care at Time of Delivery.
In New Haven again there is a chance for mothers who attend the
pre-natal clinic to have nursing care at the time of delivery. This func-
tion of the visiting nurse had been greatly neglected. All visiting
nurses care for the mother and baby beginning the day after confine-
ment, but seldom at the time of delivery. This is largely on account of
the difficulty of having a nursing force that can be on call day and
night. In some of the rural districts the nurse undertakes this work.
It is a serious question whether she is wise to do so. No person can
stand working both day and night. One nurse, for example, in a rural
community in Connecticut had the care of a child fourteen months old,
very ill with pneumonia, on whom she was making two visits a day as
the child's condition was most critical. At about eight o'clock in the
evening, she was called by the doctor to assist him at a difficult con-
finement. She returned to her home at five o'clock in the morning to
snatch a few hours' sleep. At nine she visited her little pneumonia pa-
tient again and continued her daily round.
No person can stand hours of this sort. No association should asi
nurse to do both night and day work, no matter how willing she may be.
Night work is hard under the most favorable conditions and when the
day work is such that it cannot be neglected, night work should be pro-
hibited. Skilled nursing care at delivery is what we must supply even
though it means the expense of a day and night nursing force. This
plan is practical as is being shown in a district in New York, where the
nurses are on eight hour duty.
Infant Welfare Nursing.
Only sixteen nurses are specializing in infant welfare work, but a
great deal is being done by the general visiting nurse in the course of
her daily visits.
In 1915, the Federal Children's Bureau reported nine cities or towns in
Connecticut having twelve summer and eight winter stations. Now
eleven towns and cities have twenty-four summer and nineteen winter
stations. Two of these stations still modify milk for the mothers. The
rest teach the mothers in the homes, a method that has the double virtue
of teaching the mothers the proper way to clean and sterilize their uten-
sils and of conserving the nurses' time.
PUBLIC HEALTH NURSE SURVEY
7
TABLE 2.
SHOWING INFANT WELFARE STATIONS BY CITIES.
Number Nurses.
Summer Winter
Population
Number
Stations.
Tart
Full
Tart
Full
of towns
Summer
Winter
time
time
time
time
Bridgeport . ...
3
2
1
1
3
3
3
3
2
3
3
Litchfield
1
1
1
1
Manchester
1
1
3
3
Meriden
1
1
1
1
Middletown
2
1
1
1
New Britain
1
1 ,
New Haven . .
.... 5
5
5
5
Stamford ....
1
1
3
o
Waterbury . . .
2
1
1
1
Willimantic
1
1
Total
24
19
7
16
1
15
*' ' England has recognized the need of working for its infant and ma-
ternal welfare in spite of the demands of war. The local Government
Board has taken the stand that in spite of the general need for econ-
omy, no economy should be exercised in this direction. It has estimated
that to accomplish this, one full-time health visitor for every 500 births
reported annually was necessary." The health visitor in England does
approximately the same work as our public health nurse. England has
already one health visitor for every 800 births. In Connecticut, judg-
ing by the 34,490 births reported in 1916, there should be at least 68
public health nurses doing nothing else but following up the births as
they are reported to the health authorities. As it is, we have only four-
teen public health nurses who are specializing in infant welfare work.
It would be impracticable to have specialized nurses doing this work
in our scattered rural districts, but the public health nurses doing gen-
eral work in the country districts could with advantage use this means
of developing their infant welfare work.
An occasional association, as in Waterbury, is keeping track of all its
babies until they* are two years old, both the well babies that are cared
for after deliver}', and the sick babies. One association is making an
attempt to follow the children through that neglected period from in-
fancy, when they are under the care of the infant welfare nurse, to
school age when they again come under the care of the school nurse.
•Infant Welfare in War Time, by Grace L. Meigs, M. T>.
8
PUBLIC HEALTH NURSE SURVEY
Again we find record of England's recognition of the need of this
work. The local Government Board says: f'The war has had the ef-
fect of directing greatly increased attention to means for improving the
health of mothers and their children during the first five years of life.
During 1915, work with this object has been increased, though some local
authorities still remain inert, and do not appear to realize that the
truest national economy can only be secured by saving life and improv-
ing health by all possible means."
Infant Mortality.
In the rural parts of Hartford county, the infant mortality rate is
*107 against a rate from 76 to 94 for the rural parts of the other coun-
ties. In all probabity the high death rate is due to several factors:
One is the midwife. In Connecticut, the midwife has to take an ex-
amination given by the state in order to be registered. There is no qual-
ification of preliminary training and there is no subsequent supervision.
The consequence is that she is a distinct menace. The Poles, Italians,
Lithuanians, and Eussians depend upon the midwife almost entirely. It
is a long time before they will be Americanized enough to utilize a doc-
tor at the time of confinement.
In New Haven, a typical case came to the notice of the Visiting Nurse
Association of a woman who came under the doctor's care only when
she was septic. She was in such a serious condition that she was imme-
diately sent to a hospital where she was kept under treatment for weeks
before she was well enough to be taken home. Another case was known
where the patient had a hemorrhage before the birth of the child. The
midwife did not call the doctor. When the patient had another serious
hemorrhage after the baby's birth, the doctor was called in too late to
save the patient's life. Surely the authorities should take the matter
in hand and should insist upon preliminary training. At the same time,
the local Boards of Health should be empowered to supervise the mid-
wives in their communities. This work of supervision in New York
City is quite successfully carried out by public health nurses who per-
iodically examine the midwives' bags and teach them asepsis and an-
tisepsis.
The lack of supervision of midwives leads to the practice of women
who have not registered. Some of the lack of birth registration is due to
these women. In 1916,* there were 5,365 unregistered or improperly
registered births in Connecticut. Connecticut has 93*.5 per cent re^is-
tGreat Britain Local Govt. Bd., Supp. containing Report of the Medical Officer
1915, 1916, p. 34.
*The average of the crude infant mortality rate for 1915-1016, and ten months
of 1017 are used, reckoned from the records of the monthly Bulletin of the State
Department of Health for the Counties, omitting towns of 5,000 population and
over, in order to get the purely rural districts.
*Dr. John T. Black, State Commissioner of Health.
PUI'.LIC HEALTH NURSE SURVEY
9
tration of births which would be increased if the seriousness of the mid-
wife question was recognized.
The visiting nurse associations do not report an abnormal increase in
their work this year. That the over-crowding and the high cost of liv-
ing has not induced acute illness needing the visiting nurse, does not
mean that people's resistance is not being steadily reduced. It is
against the insidious working of these conditions that the nurse can
make headway by teaching the people in their homes how to live and
what to eat.
tThe high infant mortality rate in eight different localities was at-
tributed by the health officers to the exceptionally high death rate among
the Polish and Italian babies. This is very likely true. In a study of
several sections in Hartford, Dr. Botsford, the health officer, found that
the infant mortality rate for the congested Italian section was much
higher than for the well-to-do American section of the city. For ten
months of 1917, infant mortality rate for the Italians was 145 against
112 in 1916. He felt this was due to the fact that more Italian mothers
had gone into industry this year with the direct consequence of neg-
lect of their children, especially of the nursing babies.
+Of Johnstown, Penn., it is written: "The fact is that the infant mor-
tality rate is higher among the babies of the wage earning mothers than
among others, being 188, as compared with a rate of 177.6 among the
babies of the non-wage-earning mothers."
In studying the infant mortality rates of the forty-eight towns of
5,000 population and over, it was found that nineteen have an infant
mortality rate that is 100 or under, while twenty-nine have a rate which
is higher. Considering the healthful climate and the sturdy native
stock of Connecticut, the rate should be the opposite. The causes and
the differences are too many and too complicated to deal with here.
*In Manchester, N. H., a study was made of the infant mortality and its
causes among the foreign-born mothers. It was found that the highest
rate was for babies born to French-Canadian mothers. This was 224.7.
The next highest rate was that among the babies of Polish mothers,
which was 189. This may easily account for the high infant mortality
in some towns in the eastern part of Connecticut, where the same type
of French-Canadian and Polish people live, as live in Manchester, N. H.
At no time is the infant mortality rate in the Connecticut towns so high
as in Manchester, but a rate of 129 for Killingly and of 146 for Plain-
field might easily be accounted for in this way. This is the plainest
proof of the need of infant welfare work that should be done in this
section.
tThe infant mortality rate used is the number of deaths of infants under one
year of age per 1,000 living births.
Jlnfant Mortality. Results of a Field Study in Johnstown, Pa., by Emma
Duke, Federal Children's Bureau.
♦Infant Mortality. Results of a Field Study in Manchester, N. H., by the
Federal Children's Bureau.
10
PUBLIC HEALTH NURSE SURVEY
I saw a striking example of the sort of care that a thrifty Polish
mother can give her children. The house was a frame building in the
tobacco country. The temperature outside was ten degrees below zero.
I visited this family because they lived in a town where the infant mor-
tality rate was high, and where the health officer had asserted that the
high rate was due to the large number of Polish people who worked the
tobacco fields in the summer and in the warehouses in the winter. The
house was immaculately clean, the two babies, twins, fourteen months
old, were playing on the floor. They had just two weeks before had the
crisis in a severe attack of pneumonia. The stove made the room about
the stove red hot, but the rest of the room was icy. The mother had
dressed the children in perfectly clean, clothes, and to keep them clean,
she had tied the babies' skirts about their waists. From their waists
to their knees they were perfectly naked and were sitting on the stone
cold floor. The mother was ready and even eager to be told how to
make the babies strong and well, although she was slow in understand-
ing. The Polish people seem to be more difficult to make understand
than any other nationality but when once their confidence is won a
nurse can do almost anything for them.
The living conditions also may influence the infant mortality rate, es-
pecially such as one finds in the munition centers of Bridgeport and Wa-
terbury, Ansonia and Hartford, where the past two years there has been
a great influx of labor so that rents have soared to inconceivably large
amounts.
One family in "Waterbury was visited, which was typical of the suffer-
ing caused families by the abnormal conditions. The rent during the
past year had been raised from $16 to $35. Mrs. E. had been able, with
a husband who was worthless but who paid for his board and lodging,
with two children who were working at Scovill's for good wages, and
three who were at school, to keep her five room apartment warm and
"stylish." With the raise to $25 last summer, it was hard to make
both ends meet, but with the winter raise to $35, she was in despair as
there was no place to which she could move. The only solution she
could see was to send the children away and take in boarders. An-
other consequence of city over-crowding was seen in Ansonia, where the
visiting nurse, in her search for a tuberculosis patient, found him sleep-
ing in the same room with two other men, in a bed that was to serve
two shifts of sleepers.
PUBLIC HEALTH NURSE SURVEY II
School Nursing.
-TABLE 3.
RATIO OF SCHOOL NURSES TO SCHOOL ENUMERATION AR-
RANGED BY TOWNS ACCORDING TO THEIR SIZE.
Number of towns with :
less than
3,000 chil- 3 to 7,000 7,000 and
Population No. of dren per children over per
of towns towns nurse per nurse nurse *Io nurse
Under 5,000 120 7 . . . . . 113
5,000-10,000 21 3 1 .. 17
10,000-15,000 10 3 .. .. 7
15,000-25,000 8 1 7
25,000-75,000 5 . . 2 3
75,000-160,000 4 .. 3 1
Total 168 14 13 4 137
♦From lists provided by State Board of Education, 1916-1917.
Map Number 2 shows the huge areas where no school nurses are em-
ployed, and where the school enumeration shows 94,110 children in the
elementary schools; the thirteen towns where there are enough school
nurses; thirteen where there are school nurses who can touch the most
important points in their work, and the four towns where nursing is
done, but where it is impossible for the nurses to more than scratch the
surface, are shown.
The need of follow-up work is recognized by all. Adequate home vis-
iting is impossible for over 1,000 pupils per nurse in the usual type of
graded school. In the rural districts where transportation facilities are
poor, even 800 children per nurse may be difficult to care for well. In
the city districts where the congestion makes it possible to make more
home visits, an able nurse who goes under a good medical inspector and
has the co-operation of the teachers, can give good care to 3,000 chil-
dren. If the percentage of children needing special attention is small,
as is found in many well-to-do districts, and the distances to travel are
not great, the nurse can have charge of as many as 7,000 children and
still cover some of the important points at the same time demonstrating
the need of more nurses. Complete and effective work at any time de-
pends on the hospital and clinical facilities at command and on the co-
operation of family physicians. These two points were not studied.
Comparatively little attention has been given to school nursing. A law
was passed in 1915 that every town of 10,000 population or over should
appoint a medical inspector for the schools. Every town of smaller pop-
ulation could, if it wished, appoint a medical inspector. Further,
1 _>
PUBLIC HEALTH NURSE SURVEY
PUBLIC HEALTH NURSE SURVEY
(S. 308) the Board of Education "may also appoint a matron or nurse
* * * (who) shall act under the direction of the school district, shall
visit the homes of pupils in the public schools, and shall assist in exe-
cuting the orders of the school physician." Forty-six of the 168 town-
ships have some sort of medical inspection. Thirty-one towns have an
aggregate of fifty-one nurses. This leaves large areas which have no
school nursing at all.
The few public health nurses who do school work in the rural districts,
do it as part of their program to cover the public health nursing needs
of the communities where they work, as in Eidgefield, Litchfield, Thom-
aston, Branford. M'ost valuable work can be done by this combination
which strengthens both the general work and the school work, giving
the nurse a quicker hold on the confidence of the community and, there-
fore, giving her a chance to develop her work faster along preventive
lines.
The school work in* cities has necessarily to follow different lines.
Bridgeport is an example of a plan carefully worked out by a full time
medical inspector. There are *33,357 children in Bridgeport under the
care of eight nurses, giving over 4,000 pupils to each nurse, Dr. L. A.
Wilkes, the medical inspector appointed last summer, has organized a
plan of school inspection by the nurses and doctors which promises great
results. The plan depends largely on the nurse for "normal diagnosis"
while all abnormalities are immediately sent to the doctor who is de
veloping a school dispensary for the care of these cases. Dr. Wilkes
has himself instructed his nurses with the greatest care in the different
examinations of the children and in the records which need to be kept of
the work.
There is little home visiting done except in unusual cases but the pa-
rents are urged to visit the school. Home visiting does take time, but
surely it is by home visits that the best educational work can be done.
It will be interesting to see if Dr. Wilkes can get his results with a min-
imum amount of home visiting.
Dr. Wilkes does not touch the dental work, of which entire charge is
taken by the Dental Committee who, with a dentist in charge and four-
teen dental hygienists, inspect and clean the teeth of each child in the
schools. The child is given a card with a diagram of the mouth and each
cavity marked. With this the parents are supposed to take their child
to their family dentist.
In Hartford County, the city of Hartford itself, with a school census*
numbering 26,178, has a nurse in only four of its nine school districts.
New Britain with a school census of 13,593* has only one school nurse.
It must be appalling to be faced with the problem of following the health
history of 13,593 pupils, when the ideal number for thorough work is
♦1916-17 School Enumeration of State Board of Education.
♦Board of Education School Enumeration, 1910-17.
PUBLIC HEALTH NURSE SURVEY
15
1,000 pupils. Nineteen out of the twenty-eight townships in Hartford
County have no school nursing at all. Among these nineteen towns are
some like Berlin, Plainville and Windsor Locks, with a large population
of Italians and Poles whose standards of living are such that every
means in our power should be used to teach them hygienic living.
Medical inspection, even with a full time doctor, can accomplish only
a limited amount unless followed up by visits in the home. This was
shown clearly in New York when in 1901, before school nursing began,
the medical inspectors excluded 50,000 children for various physical ail-
ments. After school nurses were established, although the total num-
ber of school children had increased, the number of exclusions decreased
to 4,000 a year. The result of keeping the children safely at school is
one great feature of school nursing. Another is prevention of epidem-
ics. A school nurse early learns to note suspicious symptoms and can
immediately send a child to the school physician for diagnosis. She can
follow the child to the home in case of positive diagnosis and there in-
struct the family in methods of isolation and disinfection which will pro-
tect them and the community.
A serious condition was reported by the teacher of a district school.
She said that a child had been taken home with throat trouble which was
later diagnosed as diphtheria. The teacher was alarmed when she heard
the diagnosis and asked that the other children in the little school should
be examined. The health officer could not give the time at that moment
to take the long ride into the rural district where the school was sit-
uated. Later, two more cases of diphtheria developed and he came. Too
late, he examined the children and fumigated the school-house. Already
one more child had contracted the disease.
The school nurses in Connecticut have duties which vary from simple
chaperoning of the school girls during the doctor's examination to the
normal diagnosis of the Bridgeport nurses. The work needs to be greatly
increased, by additional specialised nurses in the congested cities, and
by public health nurses who will do the school work as part of their gen-
eral visiting nursing.
Contagious Disease Nursing.
Hardly any public health nursing is done with contagious diseases. In
one city in the state, the nurse makes one visit in which she instructs the
family in asepsis and disinfection. In New Haven the general visiting-
nurse visits patients with measles, chicken-pox, whooping cough, and
mumps, and gives bed-side care. The work has been carried on for eight
months (150 cases) with no case of gross infection as far as could be
judged.
With our modern understanding of contagion there is no reason why
more associations should not adopt the New Haven plan and go even
further in caring for scarlet, fever or diphtheria. An intelligent nurse
can easily do this with no disastrous consequences.
i6
PUBLIC HEALTH NURSE SURVEY
Tuberculosis Nursing.
The tuberculosis problem in the state is well cared for when compared
with other states. That sanatoria are provided with more beds per pop-
ulation than other states does not mean, however, that there is not a
great deal of follow-up work which should be done. The patient, before
he goes to the sanatorium and after he comes back, is sadly neglected
in the greater part of the state.
There are in the state only fourteen nurses who are specializing in
this form of public health work. Six of them are in New Haven alone
where 269 new tuberculosis patients were cared for in 1917. Exposed to
the positive cases there were 600 children under fifteen years of age who
were cared for by the nurses.
In spite of good sanatoria that give good care there are many patients
that refuse to stay. Take the case of Julia V. in New Haven, whose
brother had died of tuberculosis. Julia's husband became a patient
when alread} r an advanced case of tuberculosis. He was sent to the san-
atorium only to refuse to stay there. Shortly after his return he died,
and in a month Julia 's baby was born. Now Julia has tuberculosis and
refuses to stay in the sanatorium. At home she is a constant menace to
her two children. The public health nurse is a stern necessity in the
care of this class of patient.
The general visiting nurse occasionally does some tuberculosis work
when there is no specialized nurse in the field. Not half enough work
is done. When one remembers the reports at the time of the draft, tell-
ing of numbers of men who were found to have the disease, one real-
izes that although much has been done, the disease is far from being
stamped out. Every community should have a public- health nurse whose
duty should be to visit the family of each reported case. Whether she
spends all her time at this particular work or does it as part of a gen-
eral nursing program, the work should be done.
Tuberculosis Death Rate.
The tuberculosis death rate is low in Connecticut. In finding the crude
tuberculosis death rate for the townships no town except the towns that
had an abnormal rate on account of a sanatorium in the place had a rate
as high as the 141.6 which is the average for the whole country. This
should be a tremendous incentive to further work.
General Visiting Nursing.
The 136 nurses classed under general visiting nurses include the six-
teen who are specializing in infant welfare and fourteen who are
specializing in tuberculosis work. Of those doing general work,
twenty-five are in the rural districts. It is in the rural communi-
ties that the visiting nurse can, with good results, include school nurs-
PUBLIC HEALTH NURSE SURVEY
17
ing with her regular work of giving bedside care to the sick in their
hones, and of preventive infant work. This is already done in some of
the rural communities, as in Litchfield, Thomaston and Branford. The
rural district nursing of necessity has different problems and develops
along rather different lines from the work in the congested parts of the
city. In several places the nurses are called upon to assist at operations.
They also in several towns have built up a pay practice. One nurse, for
example, had taken during December $61.50. This is certainly provid-
ing a service that is needed. The great danger is that on account of
pressure of work the patients who need to be sought out, the Poles, and
Italians, among whom more preventive work should be done, may be
neglected.
Hospital Social Service.
Less work is done in hospital social service work in Connecticut than
in any other line. Two hospitals and two dispensaries in the whole of
the state follow up their patients. These are the Hartford Hospital and
Hartford Dispensary, the New Haven Hospital and the New Haven Dis-
pensary. Bridgeport is planning a complete polyclinic which shall have
nurses who will be in the dispensary and also will visit the patient in
his home. Only by such a connecting link can the hospital or dispensary
know that its work is complete. Take, for example, the case of Eliza-
beth O, ten years old, with heart disease. The doctor forbade her to go
to school or to play with the children. He felt the admonition to stay
at home would keep the ehild sufficiently inactive as she lived in a tene-
ment on the first floor. The child did not improve. When the social
service nurse called, she found that the child was going up and down
stairs as much as she wanted, to friends on the third floor. Immediately
the reasons were carefully explained, why Elizabeth should not go up and
down stairs. The instructions were followed and Elizabeth's condition
improved.
Life Insurance Service.
Nursing service .supplied by life insurance companies to their policy
holders is reaching about one-fourth of the people of the state. Consid-
erable of this service is through visiting nurse associations.
[8
PUBLIC HEALTH NURSE SURVEY
Industrial Nursing.
* TABLE 4.
RATIO OF INDUSTRIAL NURSES TO THE NUMBER OF EM-
PLOYEES ARRANGED BY TOWNS ACCORDING TO THEIR SffZE.
Less than More than Towns
2,000 em- 2,000-5,000 5,000 em- Towns less more than
Population No. of ployees per employees ployees per than 1,0()(> 1,000 em-
of towns towns nurse per nurse nurse employees ployees
Under 5,000, 120
3
5,000-10,000, 21
2
3
5
112
10,000-15,000, 10
3
6
10
15,000-25,000, 8
3
1
2
4
3
25,000-75,000, 5
2
3
2
75,000-160,000, 4
1
3
Total, 168
9
12
5
15
127
♦State Department of
Factory
Inspection.
Map number 3 shows in the black areas the industrial centers where
there is one nurse for 2,000 employees.
There are ninety-nine nurses doing industrial nursing in the state, of
whom eleven are not graduate nurses. The work of a nurse in a fac-
tory is altogether too responsible for an undergraduate.
It is difficult to say how many employees a nurse can care for, depend-
ing as it does upon the answers to these questions: First, how much first
aid work does she need to do? Second, how much need is there for rest
rooms, lunch-rooms, day nurseries, etc? Third, how much need is there
for social service work in the homes of the employees? Fourth, how
much do the employers recognize the needs of their men and how much
do they feel responsible for their well-being?
Cheney Brothers, in South Manchester, with about 4,000 employees,
employ three nurses, while Scovill's, with their 13,000 employees, also
employ three nurses. In the first instance, a long established firm has
developed a system of health care that is partly supported by the em-
ployee and partly by the employer. The family of the employee also
benefits from the Cheney Brothers' Benefit Association. In the other
case, a concern whose numbers are increasing with the great war orders,
has established so far only a first aid hospital.
I was unable to visit more than eight of the plants which employ
nurses, so the examples I cite refer only to those I visited although there
are others which are doing interesting work.
In large plants, the first aid work is often very heavy, and is under
the direction of a full time physician, as at Winchester's in New Haven,
or the American Thread Company in Willimantic. The Remington
PUP.LIC HEALTH NURSE SURVEY
19
Arms, in Bridgeport, with 13,000 employees, have only a part time phy-
sician. Colt's, in Hartford, with 14,000 employees, only calls a physi-
cian when the nurse in charge thinks it necessary. This puts a great
responsibility on the nurse.
Rumor says that often a nurse will take upon herself duties which
she is not trained to meet. I could not confirm this rumor. All nurses
to whom I talked were not at all anxious to take upon themselves re-
sponsibilities that should be taken by the physician.
The duties of the nurse vary from simple first-aid work, with a doctor
on call for serious work, to elaborate hospitals with full time doctors as
at the Winchester Repeating Arms Co., in New Haven. The first-aid
work, while being the most obvious duty of the nurse, is far from being
the most important duty.
First-aid work is invaluable in keeping down the chances of infection
and also in having data for the "Workman's Compensation," but the
nurse in the factory can do much more to better the conditions of the
employee. In one of the large cotton mills, for instance, the nurse was
asked to inspect the factory and generally to oversee the cleanliness
and sanitation. In another instance, the nurse was asked to do this
and to watch for any conditions in the factory that might be detrimen-
tal to health. It was after this that she was able to have the chairs of
some twenty girls changed, so that instead of facing the windows they
sat with the windows at their left.
The growth of the nursing work in one small factory is interesting
and rather typical of what may be accomplished. When the nurse was
engaged, there was no welfare work of any kind done in the factory
which employed about 160 women and 250 men. The nurse went to the
floor where the women worked. There were girls of from 16 years old
to mature women. For three days she sat and waited, hoping that some
of the girls would speak to her, recognizing her nurse's uniform, and
give her some opening to assist them. For three days nothing happened.
Then one of the girls fainted. When she revived, she confessed to the
nurse that she came every morning without breakfast as she had to start
to work at half past six and did not have time to light the stove fire in
order to do any cooking. The nurse soon discovered that some fifty of
the women were coming to work either with no breakfast at all or with
only a cup of coffee. To' meet this need she started a ten o'clock lunch.
The girls were allowed ten minutes to get a cup of cocoa and some toast.
Charge of five cents was made for the cocoa, and they could eat as much
toast as they wished. The nurse would not give them coffee or tea, as
they one and all were used to drinking far too much of them. At first
the girls, who were for the most part Italian, did not like the idea of
drinking cocoa. In a few days, however, the nurse heard one girl say:
" Ain't it swell?" to another girl who said: "My ain't it swell,
though - NATIONAL LIBRARY OF MEDICINE
WASHINGTON, D. C.
PUBLIC HEALTH NURSE SURVEY
22
PUBLIC HEALTH NURSE SURVEY
This was the beginning of work which has extended during the past
two years to include a lunch room where noon-day meals are served to
both men and women in separate dining rooms. There is a rest-room
with magazines, a victrola, and one or two couches. The first-aid room
is small and seldom used as the machinery is well safeguarded. A day
nursery was added when it was found that a number of married women
were employed who had small children whom they left with neighbors
while they were at work. The dangers of having married women seek
a job where their children would be well cared for, was early recognized
and a rule was made that a woman should have to work for at least a
month before she could make use of the nursery.
The nurse has been able to counteract some of the effects of old-fash-
ioned "charity." One Italian woman, thirty-five years old, was left
a widow with six children, all under fourteen. She received nine dollars
a week from the factory and part of the rent of her airless attic from
the Associated Charities. Some groceries were given each week by the
city authorities. The nurse found the woman worried, undernourished,
but determined to keep her family from being scattered. She visited
the woman's home and then called upon each of the relief agencies,
ending up with procuring a raise in the woman's w r ages in the factory.
Now the woman 's family is clothed and well, and she herself is buxom
and happy. To be sure, a widow's pension would have saved all thi*
complicated machinery and would have gone farther and done better by
paying the woiran to stay at home and care for her children. However,
the family is now intact and all have enough food and clothing.
Thirty-two of the ninety-nine nurses doing industrial nursing visit in
the homes of the employees. The influence that a nurse can have is
measured only by the ability of the nurse. Where the first-aid work is
heavy, the nurse cannot leave the factory. Under such conditions sh^-
should have an assistant. In some factories the nurse visits the ab-
sentees. In others she visits also any other employees whom she can
help either by nursing care or advice. The Winchester Repeating Arms
Company has a system of home visiting that seems to work well. On
the third day of absence, an employee is visited. I£ actual bedside care
is needed the patient is referred to the New Haven Visiting Nurse As-
sociation which then takes care of the patient.
The only company that has an established plan for home care of sick
employees is Cheney Brothers, in South Manchester. The Cheney Broth-
ers Benefit Association is managed by a joint board of employees and
employers. The company gives an initial physical examination to every
applicant for employment. Each employee can, upon payment belong to
the Benefit Association which provides nursing and medical care to each
employee who belongs to the association and to any members of his
family.
PUBLIC HEALTH NURSE SURVEY
23
Lunch rooms and rest-rooms should surely be encouraged in factories.
Day nurseries should be installed in any place only as a last resort. They
make it altogether too easy for mothers to go to work. If, in spite of
all that can be done, the mothers must work and a day nursery is
started, it should be very carefully supervised. One day nursery that
I was able to visit, was the gift of the company to those of its em-
ployees who wished to use it. The house had been supplied by the firm,
and the order of Catholic nuns who lived several miles away undertook
to run it. When I saw the nursery it was one of the coldest days this
winter. The woman who had charge of the cleaning of the house, in
return for the right to live in the house, was the only grown-up person
to be seen. She was busy down stairs cleaning the stove, while up-
stairs four children from three to seven years of age were in charge of a
child of thirteen. The place was bare of games, or any sort of amuse-
ment, and was frightfully cold although the stove down-stairs was mak-
ing the lower floor comfortable. In contrast to this nursery was an-
other in one of the mill towns in Plainfield. This nursery has been given
by the mill for the care of its employees' children. There was a woman
in charge who had been selected with great care, and the place was prop-
erly furnished and warm. A day nursery is for the protection of the
children whose mothers have to go into industry. It is no protection
to give them inadequate care under the cloak of philanthropy.
Summary.
There are 282 public health nurses in the state. The 136 general vis-
iting nurses include sixteen who are engaged in infant welfare work, of
whom two do pre-natal nursing, fourteen in tuberculosis work, and five
in hospital social service work. Fifty-one are doing school work, four
of them giving only part time. Ninety-nine are doing industrial nursing.
As map Number 1 indicated, only fourteen of the 168 townships have
one nurse for less than 5,000 population. New Haven, which is in this
class and is better provided with public health nurses than any other of
the large cities, does not feel that it has enough nurses to care for all
the patients it should. Although they have six nurses who do nothing
but the tuberculosis work, they report that the field is not thoroughly
covered. The preventive work in the families of their tuberculosis pa-
tients cannot be cared for as it should be. There is need for more pre-
natal and infant welfare work.
If this is so in New Haven, how much more could an increased num-
ber of public health nurses be used in the fifteen townships where there
is one nurse to every five to ten thousand population. There are twelve
towns that have one nurse who cares for more than ten thousand popu-
lation. This leaves 127 towns with a total population of 317,526 which
have no general visiting nursing at all.
PUBLIC HEALTH NURSE SURVEY
2 J
The school nurses number fifty-one, of whom four in the rural com-
munities do general visiting nursing in addition. Fourteen towns have
one nurse for each 3,000 pupils, which is a minimum standard, while
thirteen have from three to seven thousand children per nurse, a num-
ber which allows so little time per child that it is practically impossible
ever to do thorough work even in well-to-do communities. Four towns
have over seven thousand children per nurse, and 137, with a total school
enumeration of 94,110 have no school nursing at all.
More Public Health Nurses Needed.
The State of Connecticut needs 171 more general visiting nurses and
school nurses, and 64 more industrial nurses, which are shown in map
Number 9, all making 235 more public health nurses. If we have a well
organized group of public health nurses distributed throughout the state,
when the Health Insurance Law passes there will be ready to hand a
machinery for carrying out the nursing clause which is incorporated in
the model law, giving nursing to all the employees and their families in
addition to the medical care.
Eeckoning that a general visiting nurse should be available for every
ten thousand population, the map Number 7 was drawn. If a commun-
ity of ten thousand begins with a nurse, undoubtedly it will need more
nurses as the work develops. Map Number 7 shows the minimum num-
ber of nurses. On the same map are plotted the school nurses needed,
reckoning that no school nurse should have charge of more than 3,000
children. The same map is used for both types of public health nursing
because in the rural districts the two functions are carried on by the
same nurse. In the country the specialized nurse has no place, if for
no other reason than the difficulty of transportation. It is the family
nurse who is ready to care for the pregnant mother, the baby, the tuber-
culosis patient, or the child with measles, who can do successful work in
a rural district.
In placing the nurses, two other points were carefully considered.
First and most important were the means, or often the lack of means,
of transportation. Second, all other things being equal, an attempt was
made to have several nurses from a common center rather than to have
all the townships have individual nurses working alone. It is a rare
type of woman who can do as good work alone in the field as she can do
when she comes in daily contact with her co-workers. The arrows in-
dicate the territory to be covered. The industrial nurses are not con-
sidered on this map.
In reckoning the number of industrial nurses needed, it was thought
that towns with less than 1,000 employees did not need a nurse, as the
visiting nurse in the community could be utilized. The above map shows
the 64 industrial nurses needed and their distribution. It is a perfectly
26
PUBLIC HEALTH NURSE SURVEY
feasible plan for small factories to combine and pay the salary of u
nurse. This is already being done by the Manufacturers' Liability In-
surance Company, whose nurses do first-aid work for about 150 facto-
ries in several cities. The same plan could be carried for a broader plan
of work for the nurse which could cover the various branches of wel-
fare work.
Nursing Sources.
How can all these nurses be provided? Only the best trained, regis-
tered, graduate nurse should be employed in the responsible work of pub-
lic health nursing. Furthermore, she should have the specialized train-
ing in public health work with a well organized association or with one
of the public health courses like those given to graduate nurses at Sim-
mons College, or Teachers College, Columbia University. New Haven,
Bridgeport, Hartford and Waterbury are giving public health nursing
experience to a limited number of pupil nurses. The New Haven and
Middletown Visiting Nurse Associations give a course to graduate nurses
which enables a nurse in eight months to get a good idea of the prob-
lems which she must cope with in her district work. The practical field
work is given under their staff of skilled nurses and is supplemented by
lectures on social and public health subjects given by five of the leading
Yale Medical School professors.
That the State of Connecticut is ready to develop public health nurs-
ing cannot be doubted. In the twenty-three townships visited, nine had
definite groups who were interested. In three, the money had already
been raised to support a nurse. Thirteen already had nurses. One of the
thirteen was just starting a second welfare station. Only one town was
apathetic. The opposition to public health nursing seemed to be the af-
termath of an unqualified nurse who, although a graduate, had tried to
do the work with no training in public health work and had ignominously
failed.
A public health nurse under the State Commissioner of Health would
be of invaluable service in encouraging, directing and helping these
communities who are so anxious to go ahead with public health nurs-
ing, but have so little knowledge in the subject. This expert advice could
easily be given to them by a state Supervisor of Public Health Nursing.
Recommendations.
1. There shall be appointed a public health nurse who shall be di-
rectly responsible to the State Commissioner of Health. She shall be a
graduate, registered nurse with experience in public health work.
2. Her duties shall be: (a) To encourage communities to organize for
the support of public health nurses where such an organization has not
before existed, (b) To advise with associations or individual nurses
PUBLIC HEALTH NURSE SURVEY
27
already in the field as to the development of their work, especially in
the line of child-welfare and tuberculosis work.
3. The first nurse as her work increases shall be given assistants, with
the same qualifications for the work as she has, who shall, if the work
justified it, be four in number, one for each of the sanitary districts.
The first nurse shall supervise and direct the work of the assistants.^
4. It would be advisable for the State Department of Health to have
moving pictures of public health nurses at work which could be used
through the state in connection with lectures on public health nursing.
Slides for stereopticon could be provided for use in those places where
it might be impossible to use moving pictures.
5. It would be further advisable to have an Infant Welfare Exhibit
owned by the state which could be sent about the state wherever it
might be thought expedient to use such an exhibit. This method of pub-
licity has been used successfully at county fairs, bazaars or similar
meetings.
INDEX
Maps:
Public Health Nurses, Including Industrial Nurses 1
General Visiting Nurses, Ratio to Population 4
School Nurses, Ratio to School Enumeration (1916) 12
School Nurses, Distribution of 13
Industrial Nurses, Ratio to Employee < 20
Industrial Nurses, Distribution of 21
Needed Public Health Nurses (General Visiting and Schoo") . . 24
Purpose ,. t . *
Field of Survey J
General Visiting Nursing 3
Pre-natal Nursing 5
Nursing at Time of Delivery 6
Infant Welfare Nursing 6
Infant Mortality . 8
School Nursing LI
Contagious Disease Nursing 15
Tuberculosis Nursing 16
Tuberculosis Death Rate 16
Visiting Nurses 16
Hospital Social Service 17
Industrial Nursing 18
Summary 23
More Public Health Nurses Needed 25
Nursing Sources 26
Recommendations . . 26
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